Momentum grows for sex reassignment surgery coverage

Medicare’s recent decision to cover sex-reassignment surgery was a victory for transgender advocates seeking broader access to medical care for a condition that still carries social stigma. After all, the federal health program was one of the first to exclude such treatments more than 30 years ago.

Yet a series of announcements since then shows the extent of advocates’ push to get insurance providers to share the cost of matching a patient’s outward gender and inner identity. Since the Medicare decision in May, officials have opened the door to coverage by health plans for federal employees as well as required it for many plans in Massachusetts and Washington state. About a half-dozen mostly liberal states had already expanded coverage.

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Advocates welcome the latest shifts but don’t expect a sudden domino effect nationwide. As they press for broader public acceptance, they still have to contend with what one activist called the “ick factor” in discussing sex organs with insurance regulators, private companies and federal agencies.

“Sometimes inevitability takes awhile,” said Mara Keisling, executive director of the National Center for Transgender Equality. She added wryly, “Marriage equality is still illegal in a handful of states, and the Washington football team is still called the Redskins.”

One new element: In recent regulations requiring surgery coverage, both Washington state and Massachusetts cited provisions in the Affordable Care Act barring discrimination related to gender identity. The Department of Health and Human Services does not interpret the health care law so broadly regarding sex-reassignment surgery.

With coverage still very inconsistent and change still incremental, the efforts haven’t sparked a backlash from social conservatives. The Medicare decision barely made a ripple.

And there is now a broad medical consensus affirming gender dysphoria — the diagnosis for people whose bodies do not match their self-perceived gender — as a serious condition that might require hormones, psychotherapy or surgery. The American Medical Association’s position, adopted in 2008, is that insurance companies should cover such treatment when recommended by a patient’s physician.

The treatment can be expensive, with full-body, transformational surgical procedures sometimes topping $70,000. But studies from UCLA and California’s Department of Insurance show that the overall cost to public or private employers is relatively small because so few people undergo the most extensive treatments.

In late 2012, Oregon was the first state to direct private insurers to pay for transition procedures deemed medically necessary. California, Vermont, Colorado, Connecticut and Washington, D.C., have done the same, and major cities such as San Francisco and Rochester, N.Y., cover their employees.

However, many of those decisions have limited scope. In Washington state, Insurance Commissioner Mike Kreidler cited antidiscrimination clauses in both the ACA and state law when he told insurers this spring that “transgender people are entitled to the same access to health care as everyone else.” But his notice does not apply to plans for state employees, self-insured companies or, crucially, Medicaid.

“What’s so challenging, I think, is that it’s a politically unpopular issue,” said M. Dru Levasseur, director of Lambda Legal’s Transgender Rights Project. “There’s ignorance around transgender people in general and transgender health care specifically.”

To a large degree, the coordinated coverage push has been built on the gains in the courts and the corporate world — not unlike the way that gays’ and lesbians’ push for marriage equality initially moved forward.

At least nine federal appeals courts have recognized gender dysphoria as a serious condition. Most of those cases involved prisoners seeking treatment while incarcerated, who alleged that denial amounted to cruel and unusual punishment.

Employers have also been at the vanguard, as they were when they extended domestic-partner benefits long before gay marriage became possible. At least 167 of the Fortune 1000 companies offer surgical benefits, according to the Human Rights Campaign’s Corporate Equality Index.

Still, Medicare’s announcement this spring was both a practical and symbolic shift. In 1981, the program had declared sex-change surgery “experimental,” denying coverage. Change took decades and an appeal by a 74-year-old Army veteran and transgender woman named Denee Mallon. In December, an HHS review board ruled that the rationale was outdated.

Advocates do not expect an immediate response from other federal providers. In fact, they say they’re not even going to try for coverage through the Defense Department’s TRICARE program and the Veterans Health Administration until they win a more fundamental battle: the right for transgender people to serve openly in the military.

The decisions on health plans are rarely comprehensive. The Office of Personnel Management, for example, is allowing but not requiring insurers to add coverage through their Federal Employee Health Benefit plans. Patchwork state systems mean regulators’ decisions may apply to a limited number of plans. Only three states and the District of Columbia have added the range of gender dysphoria treatments to Medicaid benefits.